Jeffrey B. Gould

School Outcomes of Late Preterm Infants : Special Needs and Challenges for Infants Born at 32 to 36 Weeks Gestation

OBJECTIVE Because limited long-term outcome data exist for infants born at 32 to 36 weeks gestation, we compared school outcomes between 32- to 33-week moderate preterm (MP), 34-36 week late preterm (LP) and full-term (FT) infants. STUDY DESIGN A total of 970 preterm infants and 13 671 FT control subjects were identified from the Early Childhood Longitudinal Study-Kindergarten Cohort. Test scores, teacher evaluations, and special education enrollment from kindergarten (K) to grade 5 were compared. RESULTS LP infants had lower reading scores than FT infants in K to first grade (P < .05). Adjusted risk for poor reading and math scores remained elevated in first grade (P < .05). Teacher evaluations of math skills from K to first grade and reading skills from K to fifth grade were worse for LP infants (P < .05). Adjusted odds for below average skills remained higher for math in K and for reading at all grades (P < .05). Special education participation was higher for LP infants at early grades (odds ratio, 1.4-2.1). MP infants had lower test and teacher evaluation scores than FT infants and twice the risk for special education at all grade levels. CONCLUSIONS Persistent teacher concerns through grade 5 and greater special education needs among MP and LP infants suggest a need to start follow-up, anticipatory guidance, and interventions for infants born at 32 to 36 weeks gestation.

Risk Factors for Early-onset Group B Streptococcal Sepsis: Estimation of Odds Ratios by Critical Literature Review

Objective. To identify and to establish the prevalence of ORs for factors associated with increased risk for early-onset group B streptococcal (EOGBS) infection in neonates. Study Design. Literature review and reanalysis of published data. Results. Risk factors for EOGBS infection include group B streptococcal (GBS)-positive vaginal culture at delivery (OR: 204), GBS-positive rectovaginal culture at 28 (OR: 9.64) or 36 weeks gestation (OR: 26.7), vaginal Strep B OIA test positive at delivery (OR: 15.4), birth weight ≤ 2500 g (OR: 7.37), gestation <37 weeks (OR: 4.83), gestation <28 weeks (OR: 21.7), prolonged rupture of membranes (PROM) >18 hours (OR: 7.28), intrapartum fever >37.5°C (OR: 4.05), intrapartum fever, PROM, or prematurity (OR: 9.74), intrapartum fever or PROM at term (OR: 11.5), chorioamnionitis (OR: 6.43). Chorioamnionitis is reported in most (88%) cases in which neonatal infection occurred despite intrapartum maternal antibiotic therapy. ORs could not be estimated for maternal GBS bacteriuria during pregnancy, with preterm premature rupture of membranes, or with a sibling or twin with invasive GBS disease, but these findings seem to be associated with a very high risk. Multiple gestation is not an independent risk factor for GBS infection. Conclusions. Mothers with GBS bacteriuria during pregnancy, with another child with GBS disease, or with chorioamnionitis should receive empirical intrapartum antibiotic treatment. Their infants should have complete diagnostic evaluations and receive empirical treatment until infection is excluded by observation and negative cultures because of their particularly high risk for EOGBS infection. Either screening with cultures at 28 weeks gestation or identification of clinical risk factors, ie, PROM, intrapartum fever, or prematurity, may identify parturients whose infants include 65% of those with EOGBS infection. Intrapartum screening using the Strep B OIA rapid test identifies more at-risk infants (75%) than any other method. These risk identifiers may permit judicious selection of patients for prophylactic interventions.

Socioeconomic status, neighborhood social conditions, and neural tube defects.

OBJECTIVES This study evaluated the contributions of lower socioeconomic status (SES) and neighborhood socioeconomic characteristics to neural tube defect etiology. The influence of additional factors, including periconceptional multivitamin use and race/ethnicity, was also explored. METHODS Data derived from a case-control study of California pregnancies from 1989 to 1991. Mothers of 538 (87.8% of eligible) case infants/fetuses with neural tube defects and mothers of 539 (88.2%) nonmalformed infants were interviewed about their SES. Reported addresses were linked to 1990 US census information to characterize neighborhoods. RESULTS Twofold elevated risks were observed for several SES indicators. Risks were somewhat confounded by vitamin use, race/ethnicity, age, body mass index, and fever but remained elevated after adjustment. A risk gradient was seen with increasing number of lower SES indicators. Women with 1 to 3 and 4 to 6 lower SES indicators had adjusted odds ratios of 1.6 (1.1-2.2) and 3.2 (1.9-5.4), respectively, compared with women with no lower SES indicators. CONCLUSIONS Both lower SES and residence in a SES-lower neighborhood increased the risk of an neural tube defect-affected pregnancy, with risks increasing across a gradient of SES indicators.

Hypothermia in very low birth weight infants: distribution, risk factors and outcomes.

Objective:The objective of this study was to study the epidemiology of neonatal hypothermia in preterm infants using World Health Organization (WHO) temperature criteria.Study Design:A population-based cohort of 8782 very low birth weight (VLBW) infants born in California neonatal intensive care units in 2006 and 2007. Associations between admission hypothermia and maternal and neonatal characteristics and outcomes were determined using logistic regression.Result:In all, 56.2% of infants were hypothermic. Low birth weight, cesarean delivery and a low Apgar score were associated with hypothermia. Spontaneous labor, prolonged rupture of membranes and antenatal steroid administration were associated with decreased risk of hypothermia. Moderate hypothermia was associated with higher risk of intraventricular hemorrhage (IVH). Moderate and severe hypothermic conditions were associated with risk of death.Conclusion:Hypothermia by WHO criteria is prevalent in VLBW infants and is associated with IVH and mortality. Use of WHO criteria could guide the need for quality improvement projects targeted toward the most vulnerable infants.

Integration of early physiological responses predicts later illness severity in preterm infants.

Physiological parameters routinely and noninvasively collected in the first 3 hours of life can accurately predict morbidity in premature infants. Not All Preemies Are Alike Premature babies can be full of surprises. Although smaller and more premature babies generally experience more complications, the hospital course of individual infants can vary greatly. Preemies born the same size and at the same gestational age can have vastly different outcomes, ranging from death to healthy survival with minimal medical problems. Ideally, the infants who are likely to do well could stay in local hospitals where they are born, whereas their high-risk counterparts would be transferred to specialty referral centers for more aggressive treatment. Distinguishing these groups of patients has been the Holy Grail of neonatology for some time, however. Ranging from the old classic, the Apgar score, to the newest inventions such as SNAP, SNAPPE, and CRIB scores, these many different prediction methods attest to the difficulty of the task. Now, Saria et al. have developed a way to take advantage of the cardiorespiratory monitors that are ubiquitous in the neonatal intensive care unit and use routinely collected data to predict infants’ clinical outcomes more accurately than can be achieved with any of the scoring systems in use today. After infants are born prematurely, they are usually attached to a cardiorespiratory monitor within minutes of their delivery. The monitors continuously display and store each baby’s vital sign data, including heart rate, respiratory rate, and oxygen saturation. This continuous stream of vital sign data continues as each infant transfers from the delivery room to the neonatal intensive care unit, and then until the patient is discharged home, or longer as necessary. Saria et al. have found that physiologic data derived from routine monitoring in the first 3 hours of life can predict future outcomes. The authors used heart rate and respiratory rate, as well as variability in these parameters, and oxygen saturation and time of hypoxia in a computational model that was able to predict the patients’ risk of future morbidity. The model proved particularly accurate in predicting the risk of high morbidity due to infections and cardiopulmonary complications, even when these were not diagnosed until days or weeks later. PhysiScore, the new method developed by Saria et al. for assessing the prognosis of premature infants, is an important development given its improved specificity and sensitivity over preexisting scoring techniques. Moreover, it relies on readily accessible noninvasive data that are already routinely collected on all infants, and can be quickly calculated by computer as early as 3 hours into the infant’s life. PhysiScore is a timely and necessary invention and has the potential to optimize medical management for most premature infants. Physiological data are routinely recorded in intensive care, but their use for rapid assessment of illness severity or long-term morbidity prediction has been limited. We developed a physiological assessment score for preterm newborns, akin to an electronic Apgar score, based on standard signals recorded noninvasively on admission to a neonatal intensive care unit. We were able to accurately and reliably estimate the probability of an individual preterm infant’s risk of severe morbidity on the basis of noninvasive measurements. This prediction algorithm was developed with electronically captured physiological time series data from the first 3 hours of life in preterm infants (≤34 weeks gestation, birth weight ≤2000 g). Extraction and integration of the data with state-of-the-art machine learning methods produced a probability score for illness severity, the PhysiScore. PhysiScore was validated on 138 infants with the leave-one-out method to prospectively identify infants at risk of short- and long-term morbidity. PhysiScore provided higher accuracy prediction of overall morbidity (86% sensitive at 96% specificity) than other neonatal scoring systems, including the standard Apgar score. PhysiScore was particularly accurate at identifying infants with high morbidity related to specific complications (infection: 90% at 100%; cardiopulmonary: 96% at 100%). Physiological parameters, particularly short-term variability in respiratory and heart rates, contributed more to morbidity prediction than invasive laboratory studies. Our flexible methodology of individual risk prediction based on automated, rapid, noninvasive measurements can be easily applied to a range of prediction tasks to improve patient care and resource allocation.

NEWBORN DISCHARGE TIMING AND READMISSIONS: CALIFORNIA, 1992-1995

Context. Hospital stays for newborns and their mothers after uncomplicated vaginal delivery have decreased from an average of 4 days in 1970 to 1.1 days in 1995. Despite the lack of population-based research on the quality-of-care implications of this trend, federal legislation passed in 1996 mandated coverage for 48-hour hospital stays after uncomplicated vaginal delivery. Objective. To assess the impact of very early discharge (defined as discharge on the day of birth) on the risk of infant readmission during the neonatal period in a California healthy newborn population. Design. Retrospective cohort study, based on a linked dataset consisting of the birth certificate, newborn, and maternal hospitalization record, and linked infant readmission records for all healthy, vaginally delivered, and routinely discharged California newborns from 1992 to 1995. Outcome Measures. Very early discharge and infant readmission during the first 28 days of life. Results. The percentage of infants discharged very early or early (after a 1-night stay) increased from 71% in 1992 to 85% in 1995. The percentage of infants discharged very early increased from 5.0% in 1992 to 5.7% in 1993 and 7.0% in 1994, then decreased to 6.7% in 1995. Characteristics that have been previously associated with suboptimal pregnancy outcomes were found to decrease the likelihood of very early discharge, eg, maternal complications, primiparity, and Hispanic, African American, South East Asian, or other Asian race/ethnicity. The rate of readmission in the neonatal period initially decreased from 27.6 infants per 1000 in 1992 to 25.67 infants per 1000 in 1994, then increased to 30.2 infants per 1000 in 1995. For infants discharged early, no statistically significant increase in the risk of readmission was observed, compared with infants discharged after a 2+-night stay. The adjusted odds ratio (OR) for readmission was statistically significantly higher for infants who were discharged very early, compared with infants discharged early (OR: 1.27), first order births (OR: 1.21), infants born to mothers who experienced complications (OR: 1.11), infants with Medicaid insurance (OR: 1.23), and infants born to mothers who received adequate plus prenatal care (OR: 1.15). The risk was statistically significantly lower for female infants (OR: 0.75). The proportion of infants rehospitalized for dehydration and low-risk infections over the 4 study years combined was statistically significantly higher in infants discharged very early (4.37‰ and 10.30‰, respectively), compared with infants discharged early (3.59‰ and 8.16‰, respectively) or after a 2+-night stay (2.91‰ and 7.95‰, respectively). The proportion of infants rehospitalized for dehydration increased statistically significantly from 2.89‰ in 1992 to 4.52‰ in 1995. Conclusions. One-night stays with adequate antenatal and postnatal care outside the hospital do not increase the risk of readmission for healthy, vaginally delivered infants born in California. However, the decision to discharge infants on the day of birth should be applied conservatively because of the increased risk of infant readmission associated with very early discharge.

Factors influencing breast milk versus formula feeding at discharge for very low birth weight infants in California.

OBJECTIVE To investigate incidence and factors influencing breast milk feeding at discharge for very low birth weight infants (VLBW) in a population-based cohort. STUDY DESIGN We used data from the California Perinatal Quality Care Collaborative to calculate incidence of breast milk feeding at hospital discharge for 6790 VLBW infants born in 2005-2006. Multivariable logistic regression was used to examine which sociodemographic and medical factors were associated with breast milk feeding. The impact of removing risk adjustment for race was examined. RESULTS At initial hospital discharge, 61.1% of VLBW infants were fed breast milk or breast milk supplemented with formula. Breast milk feeding was more common with higher birth weight and gestational age. After risk adjustment, multiple birth was associated with higher breast milk feeding. Factors associated with exclusive formula feeding were Hispanic ethnicity, African American race, and no prenatal care. Hospital risk-adjusted rates of breast milk feeding varied widely (range 19.7% to 100%) and differed when race was removed from adjustment. CONCLUSIONS A substantial number of VLBW infants were not fed breast milk at discharge. Specific groups may benefit from targeted interventions to promote breast milk feeding. There may be benefit to reporting risk-adjusted rates both including and excluding race in adjustment when considering quality improvement initiatives.

Manifestations of Poverty and Birthrates Among Young Teenagers in California Zip Code Areas

CONTEXT Given that many communities are implementing community-wide initiatives to reduce teenage pregnancy or childbearing, it is important to understand the effects of a communitys characteristics on adolescent birthrates. METHODOLOGY Data from the 1990 census and from California birth certificates were obtained for zip codes in California. Regression analyses were conducted on data from zip code areas with at least 200 females aged 15-17 between 1991 and 1996, to predict the effects of race and ethnicity marital status, education, employment, income and poverty, and housing on birthrates among young teenagers. RESULTS In bivariate analyses, the proportion of families living below poverty level within a zip code was highly related to the birthrate among young teenagers in that zip code (r=.80, p<.001). In multivariate analyses, which controlled for some of the correlates of family poverty level, the proportion of families living below poverty level remained by far the most important predictor of the birthrate among young teenagers (b=1.54), followed by the proportion of adults aged 25 or older who have a college education (b=-0.80). Race and ethnicity were only weakly related to birthrate. In all three racial and ethnic groups, poverty and education were significantly related to birthrate, but the effect of college education was greater among Hispanics (b=-2.98) than among either non-Hispanic whites (b=-0.53) or blacks (b=-1.12). Male employment and unemployment and female unemployment were highly related to the birthrate among young teenagers in some racial or ethnic groups, but not in others. CONCLUSIONS Multiple manifestations of poverty, including poverty itself, low levels of education and employment, and high levels of unemployment, may have a large impact upon birthrates among young teenagers. Addressing some of these issues could substantially reduce childbearing among young adolescents.

Effects of Maternal Drinking on Neonate State Regulation

Sleep‐awake state distribution during inter‐feed intervals over a 24‐hour period on the third day of life was investigated by means of a continuous non‐intrusive bassinet sleep monitor. 31 infants were studied: 14 born to mothers who drank heavily throughout pregnancy (group A), eight whose mothers modified their heavy drinking (group B) and nine whose mothers never were heavy drinkers (group C).

Time of birth and the risk of neonatal death

Objective: To assess whether mortality is increased in the United States in infants born at night, we compared case-mix adjusted neonatal mortality for low- and high-risk infants born during the daytime (7 am to 6 pm), early night (7 pm to 12 am), and late night (1 am to 6 am). Methods: California linked birth-death certificate data on 3,363,157 infants, weighing more than 500 g and born without lethal congenital anomalies in 1992–1999, were analyzed. Logistic regression, adjusting for birth weight, gender, prenatal care initiation, maternal hypertension, eclampsia, diabetes, and placental abruption/previa, was used to estimate the relationship between neonatal mortality and time of birth. Results: The overall neonatal mortality was 2.08 deaths per 1,000 live births. Neonatal mortality was 1.88 for daytime births, increasing to 2.37 for early night and 2.31 for late night births. After adjusting for case mix, early night births had a 12% increase and late night births a 16% increase in the odds of neonatal death, an excess that accounts for 9.6% of all neonatal deaths. Mortality was increased for night births that were less than 1,500 g or more than 1,500 g, singletons or multiples, and those delivered vaginally or by cesarean. The increased risk was identified in hospitals that provide intermediate, community, and regional neonatal intensive care, but not in hospitals that provide primary care. Conclusion: Identifying the causal factors and reducing the increased burden of mortality for infants born at night should be a major priority for perinatal medicine. Level of Evidence: III